Managing TB-HIV co-infection

Posted by: admin on: April 27, 2012

HIV and concomitant TB infection is a national threat which urgently needs to be sorted out and lot of research has been going on in this field.


The clinical course and opportunistic infections of HIV vary from patient to patient and country to country. In India TB is a major opportunistic infection in people living with HIV (PLHIV), with over 35% PLHIV co-infected with TB-HIV. There is an estimated 3.52% faster progression to death if a PLHIV suffers from TB also.

Current national TB treatment guidelines recommend that irrespective of HIV status of the patient, TB requires a minimum of 6 months of treatment with 4 drugs: Isoniazid (INH), Rifampicin (RIF), Ethambutol (EMB) and Pyrazinamide (PYZ) for 2 months followed by INH and RIF for 4 months, given either daily or intermittently.

According to Dr Manoharan, Medical Director, International Training and Education Centre on HIV/AIDS, “According to the national data of 2009, death rate is 15% in HIV positive patients with TB, and in other TB patients it is 4%. When we talk of anti TB treatment we have to cure TB, prevent relapse, and prevent drug-resistant TB. The main four issues we have to tackle while managing TB in HIV patients are: when should one start antiretroviral therapy (ART) in HIV associated TB, what should be the duration of treatment, should it be daily or intermittent therapy, and what should be done in case of relapse of infection?”

“Based on latest studies, which show that early therapy is much better than late therapy, the national guidelines of our country recommend start of ART 15 days after initiating anti-TB drugs (or when patient is stabilized on anti-TB treatment). The current recommendation is standard treatment therapy regimen extended to 9 months. However, our national guidelines recommend 6 months treatment for pulmonary TB in HIV patients. Again, the daily dose regimen has been found to be better than the intermittent thrice a week therapy, in preventing relapse. But national guidelines still follow the intermittent therapy regimen.”

Dr Manoharan also believes that, “The refampicin based therapy is far better (whether long or short duration) than non refampicin based therapy. Extending treatment of isoniazid and refampicin upto 12 months decreases the recurrence rate to 1.9%. Post treatment isoniazid for one year decreases recurrence and plays a beneficial role in preventing relapse. Cotrimoxazole propalaxsis, along with ART is beneficial in HIV-TB co-infection even when CD4 count is as high as 300 or 400. Sometimes steroids are given along with anti-TB and ART drugs.”
According to Dr Atmaram Bandivdekar, Scientist at the National Institute for Research in Reproductive Health, Mumbai, “As HIV reduces immunity of the body, many may acquire TB. To combat this problem drug adherence is very important. Also, sometimes the drug may stop responding due to virus mutations. Then one has to go for second line therapy. Multiple sex partners increase the risk of exposure to multiple viruses, as in case of sex workers. There should also be some control over the treatment available in the private sector.”

Dr Ramesh Paranjape, Director, National AIDS Research Institute, India Council of Medical Research, Pune, also agrees that: “TB/HIV co infection is a real major problem in our country. About 50% to 60% HIV patients come down with active TB. Diagnosis as well as treatment of TB is more difficult in HIV infected people, than in other TB patients. We at the National AIDS Research Institute, Pune, were the first ones to raise a red flag about HIV/TB co-infection. It may make more sense to incorporate a daily drug regimen in the Revised National TB Control Programme (RNTCP) in India, even from drug compliance point of view, as it is always easier to remember taking a pill everyday rather than on alternate days. This, along with a 9 months regimen for anti-TB treatment, will further shield better from relapses as well. The HIV virus and the TB bacteria are very good friends, and so TB and HIV programmes also will have to be friends and work hand in hand to prevent unnecessary deaths. (CNS)


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